Improving Patient Safety in Interventional Radiology: A Multi-centred Trainee-led Approach to Increasing Compliance of the Radiology WHO Checklist H Madani, A S Nelson, P Logan, N Day, A Camenzuli Objectives WHO Radiology check list Compliance rates Audit cycle improving practice Practice implications & the next steps 1
Introduction- Errors are common More than 230 million operations every year 10% of hospitalized patients experience a patient safety incident 50% of these are preventable 971 deaths in the UK (Jan 2005 - Sept 2008) A checklist is... A formal list used to identify, schedule, compare or verify a group of elements Used as visual or oral aid that enables the user to overcome limitations of short-term human memory 2
A simple checklist Simple checklists have significantly reduced morbidity and mortality in surgery National Patient Safety Agency (NPSA) between 2005 and 2008 The WHO Radiology checklist introduced throughout England and Wales 2010 Evidence of impact in surgery Before o Death rate = 1.5% o Complications = 11.0% Afterward o Death rate = 0.8% o (P = 0.003) o Complication = 7.0% (P<0.001) 3
The reality... Jan 2009 NPSA, CMO, DH, Lord Darzi Guidelines All health organisations must do check list by Feb 2010 March 2009 Royal College Radiologists (RCR) Guidelines All diagnostic and Interventional Radiology procedures requiring local and general anaesthetics 4
Royal College Radiologists (RCR) Guidelines Involve all staff in radiology department Find out existing local policies and develop protocol that complies Have an open discussion about merits & obstacles of using the checklist Take a step by step approach to creating an effective process Developed by those that use them and flexible enough to adapt to different procedure Checklist Content Patient details Request form Consent Allergies Bloods reviewed Hb, INR, Plt, egfr/cr Blood loss Cross matched Site marked Prescribed Sedation, analgesia, antiemetic BP/Pulse monitoring Essential imaging reviewed Post procedure - ward informed of after care Check list scanned into PACS 5
Aim The RCR recommends implementation of WHO checklist in all interventional procedures involving any form of anesthesia. Standard : 100 % of all Interventional Procedures 6
Method Retrospective analysis Radiology information systems of two departments Aintree University Hospital NHS Trust (hospital A) Wirral University Teaching Hospital NHS Trust (hospital B) CT and Fluoroscopy guided interventional procedures One month period in 2010 Trainee lead educational campaign Repeated study in 2011 WHO Proforma Checklist done WHO Proforma Audit Any significant findings Procedure cancelled Procedure modified Patient re-booked Cris no Date of procedure Name of procedure WHO check done Yes No If WHO check done Any significant findings noted on WHO check Yes No If Yes what was noted -------------------------------- If Yes any implication to the procedure planned Yes No If yes to above tick one of the below or fill the information. a) Procedure cancelled all together b) Procedure modified c) Patient rebooked d) Other ---------------------------------------- Follow-up of any equipment problems Yes No 7
Audit weakness Missed data - Checklist performed but not recorded e.g. during out of normal hours on call US guided procedures not included Trainee led intervention Nominated Trainee for each Hospital A systematic review of the checklist process Active involvement of departments o Interventional Consultants o Key radiographers Informative Lectures and posters Regular Updates 8
Results One month (Nov Dec) in 2010 and 2011 (Hospital B) Procedures 2010 = 123 Procedures 2011 = 119 Vascular e.g. Angioplasty, embolization Abdominal e.g. Stents, Tubograms Results Procedure mix 30 25 20 15 10 5 0 Number 9
Compliance - Aintree (Hospital A) Compliance - Arrow Park (Hospital B) 2010 46% 54% Cases with WHO Checklist Cases without WHO Checklist 10
Summary Problems identified Findings 42x Allergies e.g. medication and latex High INR, no Bloods or Cross matching 2 x Abandoned procedure Equipment availability or failures Incomplete checklists No electronic Record of checklist performed 11
Conclusion Lower than expected Radiology WHO Checklist compliance rates in multiple institutes Coordinated trainee-led educational program improved compliance Significant improvement in Patient safety standards Recommendations Verbal confirmation of checklist Everyone in the room, including the patient, are encouraged to respond (e.g. confirmation of allergy status, antibiotic or VTE prophylaxis) Completed Checklist scanned into patient electronic radiology record 12
Recommendations WHO Check list - All invasive procedures Formal listed of exceptions department policy Introduce a nominated check list Officer Active involvement of key stakeholders Exclusions? Tubograms/Linograms PICC lines HSG 13
What's next locally Reminder and promotional posters in Interventional Radiology, CT and Ultrasound departments Introduce electronic recording of WHO checklist in all departments Re-audit in 12 months The next steps: More Hospitals Large Trauma centres Smaller district departments Collaboration with Quality Improvement body National and International Presentations to raise awareness RCR national Audit 14
Acknowledgements Drs Day and Camenzuli IR teams PACS teams AQUA Advanced Quality Alliance References Haynes AB et. al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14. WEISER T G et. al. Perspectives in quality: designing the WHO Surgical Safety Checklist International Journal for Quality in Health Care 2010; 22, 5: pp. 365 370 Panesar S et. Al. The WHO checklist: a global tool to prevent errors in surgery Patient Safety in Surgery 2009, 3:9 Vincent C et. Al. Events in British hospitals: preliminary retrospective record review. BMJ. 2001 Mar 3;322(7285):517-9. Panesar SS et. al. The WHO checklist: a global tool to prevent errors in surgery. Patient Saf Surg. 2009 May 28;3(1):9. Standards for the NPSA and RCR safety checklist for radiological. 2010. Downloaded from website interventions/docs/radiology/pdf/bfcr(10)17_npsa.pdf. 2012. Guidelines for radiologists in implementing the NPSA Safe Surgery requirement. 2009. Downloaded from www.rcr.ac.uk/docs/radiology/pdf/bfcr(09)4_safe_checklist.pdf 2012. 15
Questions Hardi Madani MPhil, MBBS, MRCS Clinical Radiology Registrar Royal Free Hospital Training Rotation, London Contact: h.madani@doctors.org.uk 16